Va Pacific Island Health Care System |Honolulu, Hawaii

The American Legion SYSTEM WORTH SAVING

VA PACIFIC ISLAND HEALTH CARE SYSTEM | HONOLULU, HAWAII Date: December 6 – 8, 2016 Veterans Affairs & Rehabilitation Commission Member: Past National Commander Ronald Conley Deputy Director of Veterans Affairs and Rehabilitation Division:Roscoe Butler

Overview VA provides Home-Based Primary Care on the islands of Oahu, Hawaii (Hilo and Kona), Kauai (Lihue), Maui and Guam. In September 2016, the Department of Veterans Affairs Office of Inspector General (OIG) released a report entitled Health- care Inspection Summarization of Select Aspects of the VA Pa- cific Islands Health Care System. The report indicated that VAPIHCS is challenged with staff recruitment, retention, space, and in some cases, high-market cost issues that directly influence their ability to deliver timely care. According to the OIG report, the US Department of Health and Human Services has designated many of the counties compris- ing the VAPIHCS as Health Professional Shortage Areas. These counties have a shortage of Primary Care, Dental care, or Men- tal Health providers. Furthermore, according to a report on From The VA Pacific Island Health Care System (VAPIHCS) the findings from the Hawaii Physician Workforce Assessment provides outpatient medical and mental health care through Project (2015), the Hawaiian Islands currently have a deficit of their main Ambulatory Care Clinic (ACC) at the Spark M. more than 600 physician providers, and a projected shortage of Matsunaga VA Medical Center on Oahu (Honolulu), and sev- between 800-1,500 physicians by 2020. en Community Based Outpatient Clinics (CBOCs) located in: VAPIHCS has several key leadership vacancies. Wayne Pfeffer, West Oahu, Hawaii (Hilo and Kona), Maui, Kauai, American the medical center’s previous director, retired in February 2016. Samoa and Guam. In addition three VA Outreach Clinics exist The position of Director has since remained vacant. VA is cur- on Molokai, Lanai, and in Saipan in the Commonwealth of the rently rotating directors through VAPIHCS from other VISN Northern Marianas (CNMI). 21 facilities until a permanent director is hired. In addition to Traveling Clinicians provide episodic care on Lanai, and an In- the Director’s vacancy, the Chief of Human Resources has been ternist residing on Molokai provides medical care three days a vacant for three months and is temporarily being filled by Mr. week at the Molokai Rural Health Center. VA partners with a Gregg Wolff, Chief of HR at the Las Vegas VAMC. Additional physician practice on Saipan where Veterans receive care. Trav- key leadership vacancies include the Assistant Chief of HR that eling VA clinicians provide mental health services at all of these has also been vacant for two months. Outreach Clinic sites. The VA has a 60-bed Center for Aging, located on the Tripler Army Medical Center (TAMC) grounds which provides long term and transitional rehabilitative care services, a 20-bed ward at TAMC providing inpatient psychiatric and partial hospital- ization care, and a 12 bed VA Post-Traumatic Stress Disorder Residential Rehabilitation Program operating in a temporary site within TAMC. Physicians employed by the Department of Defense (DoD) offer inpatient care to veterans at TAMC and Guam Naval Hospital, via a sharing agreement between VA/DoD or through NON-VA care providers in the community.

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Executive Leadership Briefing their programs to prevent veteran suicides. The IG made eigh- teen recommendations: Recommendations 1. That the facility ensure that licensed independent practi- tioners’ folders do not contain non-allowed information. Target date for completion: February 1, 2016 2. That Environment of Care Committee meeting minutes consistently document tracking of identified deficiencies to closure and that monthly meetings consistently include community based outpatient clinic representation. Target date for completion: February 1, 2016 3. That Infection Control Committee meeting minutes consistently reflect discussion of identified high-risk areas. Target date for completion: June 30, 2016 4. That facility managers ensure furnishings and equipment in patient care areas are in good re- pair and have upholstery that is easily cleaned. On December 6, 2016, Past National Commander Ronald Target date for completion: February 1, 2016 Conley and Veterans Affairs and Rehabilitation Deputy Direc- tor Roscoe Butler, met with VAPIHCS Executive leadership to 5. That facility managers ensure employees routine- discuss best practices, challenges, and recommendations for ly inspect Center for Aging privacy and shower cur- improvements. In attendance were Ms. Peggy Kearns, Acting tains and initiate actions to replace those with stains. Director, Dr. William Dubbs, Chief of Staff, Tonia Bagby, PsyD., Target date for completion: December 31, 2015 Associate Director, Kate Hansen-Schmitt DNP,FNP-BC, and 6. That facility managers ensure heavy-use public re- Craig Oswald, Exec. Asst. to the Director. strooms in the ambulatory care center have fre- Attracting clinicians to Hawaii appears to be a significant chal- quent inspections and receive cleaning as needed. lenge. According to the VAPIHCS Chief of Staff, Hawaii has ap- Target date for completion: February 1, 2016 proximately 600 non-VA physician vacancies throughout the 7. That facility managers initiate corrective actions to re- state, and VAPIHCS is experiencing similar shortages. Other pair the ceiling leak in the ambulatory care center. challenges include staff recruitment and retention, space, the Target date for completion: February 1, 2016 Veterans Choice Program, and transporting veterans from Guam or American Samoa to the VA ACC , and TAMC in Ho- 8. That employees store clean and dirty items separately nolulu for care or service they cannot obtain on their home is- and promptly remove cardboard boxes from storage ar- land. Some veterans who are not eligible to receive beneficiary eas and that facility managers monitor compliance. travel1 cannot afford the airfare to Honolulu and, as a result, are Target date for completion: February 2016 not receiving needed health care, or must seek other care alter- 9. That facility managers ensure negative air pressure systems are natives outside of the VA. functional in all designated rooms and monitor compliance. Meeting with VAPIHCS Staff Target date for completion: February 1, 2016 10. That facility managers ensure all chairs in the acute psy- Immediately following the meeting with the VAPIHCS Execu- chiatry unit 3B2 dining/activity room are weighted. tive team, Past National Commander (PNC) Conley and Roscoe Target date for completion: December 31, 2015 Butler meet with VAPIHCS staff throughout the day to continue their discussions concerning best practices, challenges, and rec- 11. That the facility’s Emergency Operations Plan in- ommendations for improvements. clude all required Joint Commission elements. Target date for completion: November 20, 2015 In November 2015, the VA’s Office of Inspector General released Report No. 15-00626-28, entitled, Combined Assessment Pro- 12. That the facility implement an adequate back- gram Review of the VA Pacific Islands Health Care System Ho- up plan for a Suicide Prevention Coordinator. nolulu, Hawaii. The IG cited VAPIHCS for insufficiencies in Target date for completion: February 1, 2016

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13. That the facility implement a process for responding to During the meeting, a question arose about the methods used to referrals from the Veterans Crisis Line and for identify- provide Choice Program providers with sensitive mental health ing and tracking patients who are at high risk for suicide. and other medical documents. VAPIHCS staff who attended the Target date for completion: February 1, 2016 meeting did not know the answer, but assured us that VAPIHCS 14. That the facility ensure new employees receive suicide preven- does not refer many veterans to outside providers for mental tion training and that facility managers monitor compliance. health related conditions. Target date for completion: March 31, 2016 VAPIHCS has incorporated evidence-based care into its pa- 15. That the facility implement a process to fol- tient treatment pathways. VAPIHCS refers patients to TAMC low up on patients who miss MH appointments for treatment when they are unable to provide care to veterans. and that facility managers monitor compliance. As mentioned, this is possible through a Joint Venture Sharing Target date for completion: February 1, 2016 Agreement with the DoD. VAPIHCS spends more than $20 million annually for care provided to veterans at DoD facilities. 16. That clinicians include patients and/or their families in safety plan development and According to the VAPIHCS, of the female veterans who reported MST, 52.3 percent requested to be seen in Mental Health. In that facility managers monitor compliance. 1 Target date for completion: February 1, 2016 accordance with VHA Directive 2010-033 , every facility must have a designated MST Coordinator. However, women veterans 17. That mental health providers ensure outpatients flagged with MST are faced with a number of challenges to include ac- as high risk for suicide have a suicide prevention safe- cessing VA health care. These challenges are exacerbated when ty plan completed within the first 72 hours of con- coupled with work obligations and lack of childcare. They both tact and that facility managers monitor compliance. contribute to the difficulty women have in securing appoint- Target date for completion: February 1, 2016 ments with their healthcare providers. 18. That mental health providers ensure outpatients flagged as VAPIHCS has held several Homeless Veteran Stand Downs at high risk for suicide are evaluated at least four times within different island locations including Oahu, Maui and Guam. The 30 days of flag placement if an outpatient or at least four Stand Downs provided veterans with an opportunity to speak times within 30 days of discharge from the inpatient psychi- with staff members from the VA and community agencies such atric unit and that facility managers monitor compliance. as: VAPIHCS Homeless Program, Catholic Charities Hawaii, Target date for completion: February 1, 2016 Institute for Human Services, US Vets, Waikiki Health Center, To date, the OIG has acknowledged VAPIHCS’ successful com- Hawaii Disability Rights Center, VA Vet Center, Premier Ben- pletion of all recommendations, and the study has been closed. efits Consultants. Veterans can also receive more information on housing, employment, mental health, and education ben- Note: Document of closure provided to Mr. Roscoe Butler via efits. Other services offered during the Stand Down included email by Craig Oswald, 1/19/2017. lunch, haircuts, clothing store, eye exams, and the distribution VAPIHCS staff informed PNC Conley and Mr. Butler that all of personal supplies. Eighty veterans attended the Stand Down veterans of the VA Pacific Island Healthcare System are eligible on Oahu; 30 veterans attended the Stand Down on Maui, and 25 for the Veterans Choice Program, irrespective of the 40 mile veterans attended the Stand Down on Guam. distance and 30 day wait criteria unique to mainland U.S. How- VAPIHCS held a joint mental health seminar in Sept. 2016 with ever, veterans are not all eligible for reimbursement related to TAMC involving a full day of diverse and important presenta- travel when referred to a participating provider in the Choice tions. The seminar was well attended by staff from both orga- Program. Tri-West has 50 employees located in Honolulu, but nizations. Mental health providers from both the VA and DoD they face continued challenges in obtaining appointments for were present and earned Continuing Medical Education (CME) Veterans. Communication problems exists between the TRI- credit. West Network physicians and VA regarding the care provided to veterans and the timely availability of medical documentation from those episodes of care. These problems impact: 1 VHA Directive 2010-033, expired on July 31, 2015 • Patient safety and has not been reissued. https://www.google.com/url?sa • Dosage and length of therapy for prescription medications =t&rct=j&q=&esrc=s&source=web&cd=1&ved=0ahUKEwi WjJ6-69jSAhUrl1QKHQ_TDfAQFggaMAA&url=https%3A%2 • Length of time needed to receive an appointment F%2Fwww.va.gov%2Fvhapublications%2FViewPublication. • Ability of contract physicians to order more tests unrelated to asp%3Fpub_ID%3D2272&usg=AFQjCNEuBW8f1oEafP_aIwBoe the reason(s) for referral qXkMeP3ig&bvm=bv.149397726,d.cGw

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Facility Tour Conclusion December 8, 2016: Dr. Laura Wong VA Primary Care, escorted Leadership and staff reported their primary challenges are re- Mr. Roscoe Butler on a tour of the ACC. The clinic is housed on cruitment and retention of qualified staff due to the high-cost of three floors of a VA owned building on the grounds of TAMC living and remote location. Retention of persons in key leader- that provides outpatient primary, specialty, mental health and ship positions is also acutely challenging for the medical center. dental care. Prosthetics, laboratory, and radiology services are Their next biggest challenge is the lack of adequate space. An- also available.. other significant challenge identified was the distance between Exit Briefing the American Samoa, Guam, and the ACC in Honolulu, Hawaii. Veterans who are referred from the VA clinc in American Sa- December 6, 2016: The Acting Director and other senior lead- moa or Guam to the ACC in Honolulu, Hawaii may choose not ers attended a previously planned leadership development re- to travel to the AAC because they are not eligible for beneficiary treat. In lieu of a face-to-face exit briefing, PNC Conley and travel and can not afford the airfaire. Roscoe Butler held a teleconference call with them to discuss Lastly, women veterans find it difficult to obtain childcare -ser the results of the site visit. During the discussion, The Ameri- vices. TAMC provides childcare service for DoD and VA em- can Legion summarized their findings. Despite of the distance ployees. However, this service is not available for female vet- between the islands, VAPIHCS delivers quality healthcare to erans seeking medical care at the facility. According to the a unique group of veterans in an equally unique geographic VAPIHCS, women veterans often must bring their child or chil- setting. Due to its diverse geographic location, the Alaska VA dren to medical appointments. Health Care System is the only other VA health care system that is similar to VAPIHCS. Challenges Best Practices Recruitment and Recruitment Incentives: The VA allows VA- PIHCS to offer approved recruitment incentives when compet- • Robust and expanding telemedicine program, involving areas ing with non-VA health care providers to attract clinicians to of service such as audiology, dermatology, primary and men- Hawaii. According to the medical center’s Chief of Staff, com- tal health care munity health care institutions offer prospective candidates at- • VAPIHCS was awarded an Office of Rural Health (ORH) tractive incentives like education debt reduction bonuses that grant to develop and implement a “hub and spoke” primary help lower college debt for eligible job candidates. This type of and mental health capability during FY ’17. incentive helps draw top talent to Hawaii. While the VA does • Rural spinal cord injury and respiratory therapy/home O2 offer that incentive, the money provided by VA to VAPIHCS services in remote island locations for that purpose is not enough to attract physicians from other areas of the United States to relocate to Hawaii. Another major • Evidence-based medicine educational seminar to be held in disincentive is the high cost of housing. According to a 2016 FY ’17 survey conducted by the Missouri Economic and Research Cen- • Rural health education grants aimed at training and recruit- ter, Hawaii was among the most expensive places to live in the ing providers to VAPIHCS United States (www.missourieconomy.org/indicators/cost_of_ living/index.stm). • Affiliation Agreement and developing relationship with Uni- versity of Guam, involving nursing and other health disci- Recommendation 1: The American Legion National D.C. staff pline training and VA&R Commission will coordinate with The American Le- gion Department of Hawaii and the Department of Alaska to • VAPIHCS collaboration and participation with the Hawaii consider drafting two joint legislative resolutions. One resolu- Health Information Exchange Consortium allowing physi- tion would authorize VAPIHCS and Alaska to pay a housing cians and other medical providers to share information there- allowance to any health care provider relocating to Hawaii or by enhancing medical care provided to veterans Alaska as an incentive to attract clinicians to these areas. An- • Continued success from the Hospital at Home Program, that other resolution would seek to establish an education debt re- delivers home health care and reducing inpatient length of duction program that is specific to the VAPIHCS and VA Alaska stay Health Care System (VAAHCS).

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Recommendation 2: VISN 21 should continue searching for a VAPIHCS also reported that renovations would expand mental permanent, experienced Director while ensuring all key leader- health, physical therapy, and laboratory services at the American ship positions are filled with a sense of urgency. Samoan CBOC, which were scheduled for FY 2016. However, as February 23, 2017 Update: The medical center is now con- of August 2016, executives at VAPIHCS continue working with sidering several qualified candidates for the position of Direc- VA’s Contracting Services to resolve construction and contract- tor. Currently, the VA Central Office is conducting background ing issues. checks of identified candidates. VAPIHCS anticipates an ap- The Guam CBOC is located in Agana Heights, Guam, and pro- pointment of a permanent Director soon. vides primary care, mental health, and specialty care in person Space: The VAPIHCS is suffering from a lack of space as the vet- and via telehealth. The CBOC is not equipped to provide emer- eran population grows in the area. According to a report pub- gency services and refers patients, via a sharing agreement, to lished by the Veteran Affairs Office of the Inspector General the US Naval Hospital which is located less than 1 mile from the (VAOIG) that addresses space and access concerns, VAPIHCS CBOC. established plans for a new CBOC with 7,500 square feet on the Guam continues to experience recruitment challenges. In FY Windward side of Oahu. However, as of August 2016, leaders at 2014 and FY 2015, ten staff members left the Guam CBOC. The VAPIHCS reported they had been unable to find a suitable loca- CBOC currently has seven vacant positions: two physicians, a tion due to the constrained commercial lease market in the area. psychologist, two specialty care nurses, a pharmacist, and a so- A commercial lease broker is assisting VAPIHCS with its search cial worker. The Guam CBOC has established a successful rela- for additional space and will assist with the lease agreement once tionship with the University of Guam for training, attracting and suitable space has been identified. Moreover, VAPIHCS has es- recruiting graduates from the nursing and health-related degree tablished an emergency lease at the downtown Federal Building programs. for 5,000 sf to support administrative functions, thus increasing The Guam CBOC occupies 5,818 square feet, which is not ad- space at the ACC for clinical functions. equate to meet the present demand for care. VAPIHCS has re- VAPIHCS received approval for a 66,000 net useable square ceived approval for a $5.5 million construction project that in- feet (NUSF) multi-specialty CBOC that will to be located in the cludes renovating current space and adding an additional 2,800 “western/leeward” area of Oahu. The project is scheduled for ini- square feet. The design phase was scheduled to begin in FY 2016 tiation in the year 2020 and will serve an estimated one-third of with an expected completion timeframe of two years. VAPIHCS the veteran enrollee population on Oahu. This will almost dou- plans to enhance current space to address it immediate needs ble the capacity for the delivery of clinical care and offer con- through renovations. venient access to veterans who typically travel long distances at Recommendation: VAPIHCS Executive Leadership ensure that significant financial costs traveling to TAMC. the space allocations for each of the above CBOCs is adequate to The American Samoan CBOC is located in Pago Pago in the meet the currret and furture needs of veterans. South Pacific Ocean. The CBOC opened in 2008 and provides Travel from American Samoa or Guam to the ACC: Accord- Primary Care and Mental Health services and uses telehealth ing to the September 2016 OIG report, travel can be difficult, as for many other services. Traveling specialty VA physicians also flights to and from American Samoa and Oahu are limited. Due come from Honolulu to provide patient care. The CBOC is not to VA’s rules governing eligibility for beneficiary travel, some vet- equipped to provide emergency services. Veterans living in erans who live on American Samoa or Guam who are referred to American Samoa, as a result of their citizenship, are eligible to the ACC are ineligible for bene. Travel and may forgo the needed receive services from the Lyndon B. Johnson Tropical Medical health because they can not afford the airfare to include the costs Center in Pago Pago for urgent and emergency care. Leadership of an accompanying loved one. informed us that the local community is trying to build a new hospital. Also, the avalibility of travel can be difficult, as flights Recommendation 1: The American Legion National D.C. staff available to and from American Samoa and Oahu are limited to and VA&R Commission will coordinate with The American usually twice per week. Legion Department of Hawaii and the Department of Alaska to consider drafting a joint legislative resolution.

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Recommendation 2: The legislative resolution would provide the February 23, 2017 Update: All top management positions, authority for VAPIHCS and VAAHCS to pay for veterans’ travel with the exception of the Director, have been filled. The vacancy expenses who live on American Samoa, Guam, or Alaska when for Chief of HR has also been filled. The new Chief of HR has referred to the parent facility by VA clinician and have no means been well received and has proven to be is a very effective, com- to pay for the airfare. petent manager in a short period of time. Child Care Services: Women veterans find it difficult to take time off from work for visits to their health care provider. Com- pounding this difficulty is arranging for childcare to attend a medical appointment. In 2012, the Women Veteran Task Force issued their report, which included a section on childcare. The Secretary’s Advisory Committee on Women Veterans recommended that VA provide childcare options for eligible veterans, utilizing public and private partnerships, in order to facilitate their access to quality health care services. Under the Caregivers and Veterans Omni- bus Health Services Act of 2010 (PL 111-163), Congress required VA to implement a two-year childcare pilot in no fewer than three separate Veteran Integrated Service Networks (VISN). The law requires that the pilot program assess the feasibility and ad- visability of providing assistance for childcare to qualified veterans receiving VA care. Since many veterans, particularly women veterans, are the primary caretakers for young children, it is hoped these childcare centers will make it easier for such veterans to utilize VA. In a survey, VA found that nearly one third of veterans were interest- ed in childcare services and more than 10 percent had to cancel or reschedule VA appointments due to lack of childcare. The in- tent is to diminish barriers for veterans who have difficulty keep- ing appointments due to child care obligations. The law limits the provision of childcare assistance to these pilot programs, and eligibility is defined as being for qualified veterans receiving VA health care services on an outpatient basis at a VA facility. The pilot program authorized by Congress has ended and there are still some VA medical centers that are not making childcare available to veterans seeking care at their medical center. Recommendation: Request the VAPIHCS Executive Leadership explain the barriers to providing childcare services to veterans so that The American Legion can take appropriate action to address this concern. Key Leadership Turnover: VAPIHCS has experienced a high rate of leadership turnover in recent years. The lack of constant leadership is not good for any organization. It often limits the medical center for implementing new changes until a permanent leader is hired. Recommendation: VAPIHCS Executive leadership should include in their strategic plan short-and-long term goals for stabi- lizing key leadership positions.

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